THE CRITICAL COMPLCATIONS AND MANAGEMENTS AFTER PANCREATIC SURGERY 2013/12/21

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1 THE CRITICAL COMPLCATIONS AND MANAGEMENTS AFTER PANCREATIC SURGERY Tsann-Long Hwang, MD, FACS Department of Surgery Chang Gung Memorial Hospital Chang Gung University Taipei, TAIWAN 2013/12/21

2 THE DIFFICULTY OF PANCREATIC SURGERY

3 ADVANCE OF PANCREATIC SURGERY AFTER WHIPPLE

4 COMPLICATED VESSELS AROUND THE PANCREAS

5 SURGERY FOR RESECTABLE PANCREATIC HEAD/DISTAL TUMOR

6 CLASSIC WHIPPLE OPERATION VS PPPD (PPPD op.) (Classic Whipple op.)

7 PALLIATIVE SURGERY FOR UNRESECTABLE PANCREATIC CANCER

8 THE MORTALITY OF PANCREATIC SURGERY

9 /2045 (61.2%) 60.0 Per rcent (%) /2045 (38.8%) 702/2045 (34.3%) 253/773 (32.7%) 414/1057 (39.2%) /773 (7.1%) M F Gender Resect ability Morbidity Mortality Adjuvant Chemotherapy Important Data of Pancreatic Cancer Surgery in 6 Major Centers in Taiwan

10 /2045 (61.2%) 60.0 Per rcent (%) /2045 (38.8%) 702/2045 (34.3%) 253/773 (32.7%) 414/1057 (39.2%) /773 (7.1%) M F Gender Resect ability Morbidity Mortality Adjuvant Chemotherapy Important Data of Pancreatic Cancer Surgery in 6 Major Centers in Taiwan

11 NO. OF PANCREATIC RESECTED IN CGMH

12 NO. OF TYPES OF SURGERY IN CGMH

13 TYPES & COMPLICATIONS IN CGMH p=0.148

14 1. Bleedings COMPLICATIONS AFTER PANCREATIC SURGERY 2. Fistula: pancreatic, duodenal, biliary / gastric 3. Delay gastric emptying 4. Pancreatitis 5. Metabolic problems: DM, exocrine insufficiency 6. Others: infection marginal ulcer, mesenteric thrombosis, distal CBD stricture, multiple organ failure

15 COMPLICATIONS OF PAN. SURGERY

16 COMPLICATIONS OF PAN. SURGERY

17 1. Bleedings COMPLICATIONS AFTER PANCREATIC SURGERY 2. Fistula: pancreatic, duodenal, biliary / gastric 3. Delay gastric emptying 4. Pancreatitis 5. Metabolic problems: DM, exocrine insufficiency 6. Others: infection marginal ulcer, mesenteric thrombosis, distal CBD stricture, multiple organ failure

18 POSTOPERATIVE BLEEDING Definition: Need for replacement with at least four packed RBC units, at least 24h after the end of operation.

19 TWO MAJOR TYPES OF POSTOPERATIVE BLEEDING 1. Luminal bleeding: Gastric bleeding Anastomotic bleeding 2. Extra-luminal bleeding: Op fields related vascular bleeding

20 TREATMENT OF DELAYED POST-OP. LUMINAL BLEEDING 1. Gastric bleeding: Endoscopic ex. using PPI or endoscopic therapy 2. Anastomotic bleeding: Endoscopic ex. using PPI or endoscopic therapy Interventional radiology - TAE

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22 BLEEDING SOURCES OF POSTOPERATIVE BLEEDING

23 BLEEDING SOURCES OF POSTOPERATIVE BLEEDING

24 SOURCE OF BLEEDING & MANAGEMENT AFTER PANCREATIC SURGERY (Schafer M, et al. HBP 13:132-38, 2011)

25 Risk Factors of Massive Bleeding Related to Pancreatic Leak after Pancreaticoduodenectomy Risk Factors p value Infectious clinical signs Bile in drainage Type of pancreatic anastomosis 0.12 Texture at neck resection site 0.83 (Tien YW, et al. J Am Coll Surg 201:554--9, 2005)

26 TREATMENT OF OF EXTRA-LUMINAL BLEEDING 1. Conservative treatment: Transfusion, prn 2. Angiographic examination: Using T.A.E.

27 Angiography is Indicated for Every Sentinel Bleed after Pancreaticoduodenectomy Results: Sentinel bleed was detected in 20/283 pts., and pseudoaneurysm was detected in 7 patients (35%) by angio. Conclusions: Bleeding related mortality was significantly less than no angiography (Tien YW, et al. Annals Surgical Oncology 15: , 2008)

28 MANAGEMENT PATHWAY FOR EARLY POST-PANCREATIC OPERATIONAL BLEEDING E.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

29 MANAGEMENT PATHWAY FOR EARLY POST-PANCREATIC OPERATIONAL BLEEDING E.PPOB Lum. bleeding E.L. bleeding Endoscopy Re-operation No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

30 MANAGEMENT PATHWAY FOR DELAYERD POST-PANCREATIC OPERATIONAL BLEEDING D.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

31 MANAGEMENT PATHWAY FOR DELAYERD POST-PANCREATIC OPERATIONAL BLEEDING D.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

32 MANAGEMENT PATHWAY FOR DELAYERD POST-PANCREATIC OPERATIONAL BLEEDING D.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

33 MANAGEMENT PATHWAY FOR DELAYERD POST-PANCREATIC OPERATIONAL BLEEDING D.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

34 MANAGEMENT PATHWAY FOR DELAYERD POST-PANCREATIC OPERATIONAL BLEEDING D.PPOB Lum. bleeding E.L. bleeding Endoscopy Angiography No stop Stop Bleeder:+ Bleeder:- ReEndo/TAE TAE IA Vasopres. or Surgery Stop No stop Stop No stop Surgery Surgery

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39 MORBIDITY OF PATIENTS WITH DIFFERENT OPERATIVE PROCEDURES Postoperative bleeding GI fistula Ventral hernia 1. Sump tube drainage 19.4% 3.3% 4.9% 2. Open packing 10.0% 8.2% 13.9% 3. Irrigation lavage 13.3% Resection debridement 33.3% 0 0 (Hwang TL, et al. Hepato-Gastroenterology 42, 1995)

40 POSTOP. BLEEDING AFTER SURGERY OF AC. PANCREATITIS IN THE PAST 5 YEARS Op. Method Postop. Bleeding Treat. & Result Marsupilization 2 Debridement (2) & Packing Sump Drainage 10 TAE (4) OP with ligation (6) (Hwang TL, et al. Hepato-Gastroenterology 42, 1995)

41 MANAGEMENT OF POSTOP. BLEEDING IN SOME REPORTS

42 1. Bleedings COMPLICATIONS AFTER PANCREATIC SURGERY 2. Fistula: pancreatic, duodenal, biliary / gastric 3. Delay gastric emptying 4. Pancreatitis 5. Metabolic problems: DM, exocrine insufficiency 6. Others: infection marginal ulcer, mesenteric thrombosis, distal CBD stricture, multiple organ failure

43 LOCATIONS OF LEAKAGE AFTER PANCREATIC SURGERY

44 DEFINITION OF PANCREATIC FISTULA Output of any measurable volume of drain fluid on or after postoperative day 3, with amylase content > 3 times the upper normal serum value along with a clinical grading system to assess the impact of fistula on patients postoperative course. (Bassi C, et al. Surgery 138:8-13, 2005)

45 CLASSIFICATION OF PANCREATIC FISUTLA Classification Definition 1 Output > 10 ml/d of amylase-rich fluid after postoperative day 5 or for > 5 days 2 Output > 10 ml/d of amylase-rich fluid after postoperative day 8 or for > 8 days 3 Output > 25 ml/d and 100 ml/d of amylaserich fluid after postoperative day 8 or for > 8 days 4 Output > than 50 ml/d of amylase-rich fluid after postoperative day 11 or for > 11 days

46 MANIFESTAITONS FOR DIFFERENT GRADES OF PANCREATIC FISUTLA (Dellaportas D, et al. World J Gastroenterology 27:381-4, 2010)

47 MANAGEMENT OF PANCREATIC FISTULA A. Conservative management: 1. Nasogastric drainage 2. TPN 3. Reducing pancreatic secretion 4. Percutaneous drainage

48 MANAGEMENT OF PANCREATIC FISTULA B. Surgical management: 1. Repair the site of leakage with wide peripancreatic drainage 2. Alternative pancreatic enteric anastomosis 3. Completion pancreatectomy

49 INCIDENCE AND MANAGEMENT OF PANCREATIC FISUTLA (Dellaportas D, et al. World J Gastroenterology 27:381-4, 2010)

50 1. Bleedings COMPLICATIONS AFTER PANCREATIC SURGERY 2. Fistula: pancreatic, duodenal, biliary / gastric 3. Delay gastric emptying 4. Pancreatitis 5. Metabolic problems: DM, exocrine insufficiency 6. Others: infection marginal ulcer, mesenteric thrombosis, distal CBD stricture, multiple organ failure

51 DEFINITION OF DELAY GASTRIC EMPTYING Persistent secretion of gastric juice more than 500 ml/day for > 5 days or recurrent vomiting in combination with swelling of gastrojejunostomy / duodenojejunostomy and dilatation of the stomach in contrast medium passage studies. (Seiler CA, et al. J Gastrointestinal Surg 4:443-52, 2000)

52 INCIDENCE OF DELAY GASTRIC EMPTYING Authors(Ref) Year Type of study Patient number PPPD WPD PPP D DGE incidence WPD Van Berge HMI et al (3) 1997 Retrospective % 34% Seiler et al (4) 2000 RCT % 45% Tran et al (5) 2004 RCT % 23% Lin et al (6) 2005 RCT % 0% RCT: Randomized controlled trial PPPD:Pylorus preserving pancreaticoduodenectomy WPD:Whipple procedure (Seiler CA, et al. J Gastrointestinal Surg 4:443-52, 2000)

53 FACTORS LELATED TO DELAYED GASTRIC EMPTYING A. Intraoperative factors: 1. Vascular 2. Neural 3. Extent of LNs dissection B. Postoperative factors: 1. Intra-abdominal abdominal sepsis 2. Somatostatin analogue

54 MANAGEMENT OF DELAYED GASTRIC EMPTYING A. Conservative management: 1. Nasogastric drainage 2. TPN or PPN 3. Reducing pancreatic secretion

55 1. Bleedings COMPLICATIONS AFTER PANCREATIC SURGERY 2. Fistula: pancreatic, duodenal, biliary / gastric 3. Delay gastric emptying 4. Pancreatitis 5. Metabolic problems: DM, exocrine insufficiency 6. Others: infection marginal ulcer, mesenteric thrombosis, distal CBD stricture, multiple organ failure

56 THE ANNULAR MORTALITY OF ACUTE PANCREATITIS IN CGMH Total Total Cases Male Female (1.5/1) Mortality Mor. Rate 2.89% 4.06% 2.99% 1.59% 2.04% 2.87%

57 INTENSIVE TREATMENT & OUTCOME OF SEVERE ACUTE PANCREATITIS 3<R. S.<6 R.S.>6 Total Patients no Early complications Late complications Operation Mortality 1 (4.3%) 4 (21%) 5 (12%) (Hwang TL, et al. Hepato-Gastroenterology 42, 1995)

58 THE SEVEREITY GRADING OF PANCREATIC TRAUMA

59 THE COMPLICATIONS AFTER SURGERY FOR PANCREATIC TRAUMA (Al-Ahmadi, Ahmadi, et al. J Can Chir 51, 2008)

60 SUMMARY 1. The complications after pancreatic surgery were not low, which had no relation to the operative types. 2. Endovascular intervention represents the first-line treatment for hemorrhage from pseudoaneurysms after pancreatic surgery. 3. Endovascular embolization or stent-graft placement should be selected individually depending on the involved artery and its vascular anatomy.

61 THE DIFFICULTY OF PANCREATIC SURGERY

62 Thanks for your attention!